Public Health Accreditation Board Board of Directors Meeting | November 28-29, 2012

Ritz-Carlton Phoenix | Phoenix, AZ

MEETING AGENDA FOR PARTNERS AND INVITED GUESTS

All meetings will be held in the Terrace Room on the Second Floor. Conference Line Phone Number: 1.866.734.7792 / Conference Line Access Code: 1076445#

Wednesday, November 28, 2012 6:30 pm Dinner for Board Members, Partners, and Invited Guests

The Capital Grille at the Biltmore Fashion Park 2502 East Camelback Road, Phoenix, AZ 85016

Thursday, November 29, 2012 9:00 am Breakfast for Board Members, Partners, and Invited Guests 9:30 am Accreditation Program Report (Robin Wilcox, Chief Program Officer)

Centralized States Update 10:00 am Think Tank Planning and Reports (Kaye Bender)

Territorial Presentation

Ethics and Health Equity Planning

Jail and Prison Health 10:30 am Break 10:45 am Proposed Restructure of the Research and Evaluation Committee (Les Beitsch, Chair)

[ACTION ITEM]

11:15 am National Indian Health Board Partner Update (Paul Allis, NIHB Director of Public Health

Programs) 12:15 pm Lunch and Checkout Break 1:30 pm Centers for Disease Control and Prevention and Robert Wood Johnson Foundation Updates

Liza Corso, CDC Office of State, Tribal, Local, and Territorial Support

Pamela Russo, RWJF Public Health Team 3:00 pm Adjourn

Date: November 9, 2012 To: Carol Moehrle Chair, PHAB Board of Directors

From: Robin Wilcox Chief Program Officer

Re: Program Update I am pleased to provide the Board of Directors with a report of the program activities of PHAB since their September 2012 meeting. 1. Health Department Application Process As of November 9, there are a total of 105 health departments in the e-PHAB system. This includes health departments that have submitted their SOI; have submitted their application, paid the fee, and attended training; are uploading their documentation; are responding to PHAB’s completeness review; and have completed their site visit. Site Visits have been conducted for four health departments. There are an additional thirteen Site Visit Teams in the process of reviewing health departments’ documentation. Site Visit Teams are assigned to health departments as the health departments complete and submit their documentation to PHAB. The Board may recall that Site Visit Reports are due to be completed by the Site Visit Team within two weeks of the conclusion of the Site Visit. After staff review, the Report is provided to the health department for no more than 30 days for their review for inaccuracies. After the health department’s review is complete, the Site Visit Report is forwarded to the Chair of the Accreditation Committee for assignment of two Committee members as a primary and secondary reviewer. Upon completion of the assigned reviewers’ assessment of the Report and submission of an accreditation status recommendation, the Accreditation Committee will meet and make an accreditation status determination. 2. Applicant Health Department Training and Technical Assistance On November 8 and 9, PHAB conducted its fourth two-day training session for health department Accreditation Coordinators. Ten health departments were represented for a total number of 18 trainees. The training was very well received. It addressed:

a. Roles of participants in the accreditation process, b. Uploading documentation using e-PHAB; c. Selection and submission of documentation to PHAB, d. Interpretation of the PHAB Standards and Measures, Version 1.0; e. Preparation for the site visit, and f. Legal, communication, and conflicts of interest issues.

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It should be noted that PHAB requires that the health department’s Accreditation Coordinators complete an evaluation of the training before they are granted access to the e-PHAB module where they upload documentation. PHAB takes the results of these evaluations very seriously and revises each training session for continuous quality improvement. PHAB also continues to provide regular technical assistance to health departments as they have questions about the intent and interpretation of the Standards and Measures, Version 1.0. We continue to organize the questions and their answers by domain, standard, and measure. These questions and answers will, collectively, provide guidance for topics and issues to include in webinars, site visitor training, site visit reviews, Accreditation Coordinator Training, and the future revision to the standards and measures. 3. Site Visitors On November 15 and 16, a fourth training was held for site visitors. There were 17 attendees. These trainees were specifically invited to be site visitors based on their previous involvement with PHAB (e.g., workgroup member, Think Tank participant, etc.). The purpose of the training was to instruct site visitors on:

• Conducting a professional and informative health department site visit; • Implementing PHAB’s site visit, review, and Site Visit Report development process; • Operating the e-PHAB information system; • Accurately assessing a health department’s conformity with the PHAB standards and

measures; and, • Writing a comprehensive Site Visit Report that provides the PHAB Accreditation Committee

with information needed for them to make an appropriate accreditation status decision. The training was very well received. We have adjusted the training to take advantage of the experience gained by Accreditation Specialists from the first several site visits. We have gained insight into what information should be emphasized during the training and have adjusted the presentations accordingly. PHAB staff is continually developing further guidance and technical assistance for site visitors. Attached is guidance on the development of site visit agendas. PHAB also developed a webinar for site visitors on points to remember as they conduct site visits (see #4 below). PHAB continues to develop and refine internal procedures for PHAB support to health departments and site visitors throughout the site visit process. This includes scripts, talking points, and procedures. PHAB is working to further develop the pool of trained site visitors through an online call for volunteers that will be released at a later date. 4. Education and Training PHAB conducted an APHA Learning Institute that was attended by 34 individuals. The purpose was to provide guidance on the selection of documentation for PHAB accreditation. The agenda contained a session on PHAB’s documentation requirements and a hands-on exercise of documentation evaluation and selection from multiple examples. There was very positive feedback from participants. In attendance were several representatives of PHAB’s partners, who stated that the training was helpful in providing them with guidance for documentation technical assistance for applicants. A new module for site visitors was added in October to our online trainings. The module, titled “Conducting the Site Visit”, gives specific advice and guidance for the site visit team as they conduct a

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site visit, including leading the sessions of the site visit, conducting interviews and what to say or not to say. 5. Think Tanks PHAB has not held a Think Tank since the September Board meeting. We have begun the planning for a Think Tank to address public health ethics; a call was conducted with a planning group to identify the goals, process, and participants.

PHAB is also planning a Health Equity Expert Panel. PHAB has reached out to its partners to identify participants. More discussion on this will be held at the board meeting.

Chronic Disease and Communication Sciences Think Tanks are also being planned, as well as second sessions for Workforce, MCH, Emergency Preparedness and Informatics. A detailed Think Tank Report is provided in your board meeting materials, and additional discussion will be held on the initial territorial work at the board meeting.

6. Other Program Activities PHAB is very pleased to announce that Brittan Wood, MPH, has joined the PHAB Program Team as an Accreditation Specialist as of October 22, 2012. Brittan’s accreditation experience began in 2005 at the Rockingham County Department of Public Health where she played an integral part in the department’s accreditation process through the North Carolina Local Health Department Accreditation program. In 2007, Brittan joined the staff at the North Carolina Institute for Public Health at UNC Chapel Hill as a State Accreditation Coordinator for the NC Local Health Department Accreditation program. Most recently, Brittan served as the Accreditation Administrator for NC’s program, thus bringing a wealth of knowledge and public health accreditation experience to PHAB. Brittan lives in Greensboro, NC and holds a master’s in public health from the University of North Carolina at Greensboro. The Accreditation Committee is scheduled to hold its third meeting on November 27th. Since the September Board meeting, the Committee has revised the Policies and Procedures in accordance with decisions made at the September meeting. The November meeting will be dedicated to working through case studies to test the Committee’s discussion and consensus process. PHAB staff has begun the review of the Standards and Measures, Version 1.0 and the Acronyms and Glossary of Terms, Version 1.0 for edits and revisions. The first step is to consider edits and wording changes for clarification. The Program Team is working closely with Jessica Kronstadt, PHAB’s Director of Research and Evaluation, on the evaluation processes for education and training, the site visit process, and site visitors. Questionnaires and evaluation forms are being developed. In a separate report you will learn of the work of the PHAB Board Ad Hoc Committee to review the PHAB policies that relate to centralized states and the third category of application (“State health department application for some or all of its local health departments in the state”). The Committee has held three meetings. PHAB program staff continues to work closely with Liaison International through the development, testing, and implementation of e-PHAB, and through the identification in problems that are identified as we use e-PHAB. As to be expected, numbers of unanticipated “glitches” are being identified through the site visit

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process. Additionally, we are working to develop the e-PHAB steps for the requirement of an Action Plan and the health department’s response to that requirement. 7. Presentations Since the September Board Meeting 1. Public Health Accreditation: What’s It All About? Mississippi Public Health Association Annual

Meeting, Philadelphia, MS, 09-13-2012. 2. Public Health Accreditation Overview for Territories. Special Session with Pacific Island Territories

and Freely Associated States. Honolulu, HI, 10-6-2012. 3. Public Health Accreditation for State Health Departments. Special Session with the Hawaii State

Health Department Leadership. Honolulu, HI, 10-8-2012. 4. Public Health Accreditation, Performance Management and NPHII. Pacific Global Health Conference.

Honolulu, HI, 10-9-2012. 5. Accreditation for Boards of Health, Nebraska Boards of Health Web Conference facilitated by the

Public Health Association of Nebraska, Lincoln, NE, 10-09-2012. 6. Role of Statutes & Regulations in Accreditation, panelist, National Public Health Legal Conference,

Atlanta, GA, 10-11-2012 7. Accreditation: A Dialogue and Workshop. Maryland Rural Health Association, Solomon Island, MD,

10-18-2012. 8. One Year of Accreditation: So What’s Up? Nebraska Preparing for Accreditation Workshop, Nebraska

Dept. of Health & Human Services & the Public Health Association of Nebraska, Lincoln, NE, 10-25-2012

9. PHAB Update. ASPH Associate Deans for Practice. October 26, 2012, San Francisco, CA. 10. Evaluating and Selecting Documentation for Accreditation Measures. American Public Health

Association Learning Institute, 10-28-2012. San Francisco, CA. 11. PHAB Update. ASPH Accreditation and Credentialing Committee. October 28, 2012. San Francisco,

CA. 12. Public Health Department Accreditation: One Year Later. APHA Annual Meeting. October 30, 2012,

San Francisco, CA.

Attachments: Guidance for the development of site visit agendas Map of Health Departments in e-PHAB

SITE VISIT AGENDA GUIDANCE FOR AGENDA DEVELOPMENT

DRAFT October 4, 2012

A. SITE VISIT AGENDA DEVELOPMENT PROCESS

I. Site Visit Team Develops a Draft Agenda When the Site Visit Team has completed the Pre-site Visit Review, the Team will immediately begin the development of a proposed agenda for the Site Visit. The Team should use the PHAB Site Visit Agenda Template (Appendix B of the PHAB Site Visitor Guide, pages 41 and 42) as a guide.

• The Template may be adjusted to address the Site Visit Team’s information needs. • A word version of the template is available from your Accreditation Specialist.

The Site Visit Team’s process for developing the proposed agenda should follow the six steps below:

1. Start the development of the agenda with the agenda items that are set (see below). 2. Consider items that have a recommended place on the agenda (see below). 3. Schedule the walk through of the department. 4. Schedule interviews (see guidance below). 5. Schedule Executive Sessions throughout the agenda. 6. Schedule travel and visit time to additional facilities to be visited, if any.

A health department may request visits to up to four additional sites (in their application). Visits to additional sites are at the discretion of the Site Visit Team (see PHAB Site Visit Team Guidance for Additional Sites or Facilities on the Site Visit Agenda, July 9, 2012).

II. The Agenda is Finalized The Site Visit Team will submit the proposed agenda to the PHAB Accreditation Specialist. The Accreditation Specialist will review the agenda with the health department’s Accreditation Coordinator. The order of the sessions and times allotted for each of the interviews and discussions may be altered by the health department based on its scheduling parameters. The Site Visit Team will have an opportunity to review revisions to the agenda and make any final changes. The Accreditation Specialist will share the final version of the Site Visit Agenda with the health department. It is recommended that the agenda be finalized at least two weeks prior to the Site Visit.

Draft October 4. 2012 2

B. SITE VISIT AGENDA DEVELOPMENT CONSIDERATIONS

I. Starting and Closing Times PHAB will notify the Team Chair of the hours of operation of the health department. The agenda should begin at least 30 minutes after the opening time of the health department, to allow for security and getting settled.

II. Standard Agenda Items There are three items that are set and cannot be moved on the agenda:

• The Entrance Conference is the first agenda item. • An Executive Session is held immediately before the Exit Conference.

This session is to review findings that will be shared with the health department. • The Exit Conference is the last agenda item.

III. Agenda Items Recommended Placement There are three items that PHAB recommends be placed at certain points in the agenda, but may be adjusted to suite the scheduling needs of the health department:

• The CHA/CHIP Review interview should be held immediately after the Entrance Conference. The CHA/CHIP provide the context and foundation for the health department’s programs, policies, and processes and a framework for the Site Visitors’ review.

• The Strategic Plan interview should be held immediately after the CHA/CHIP interview. The Strategic Plan provides the direction of the health department and the template for decisions to move the department forward. It provides Site Visitors’ with an overall understanding on the health department’s priorities and operations.

• An interview with the health department director should be held before the Site Visit’s Team final Executive Session. This interview is recommended to be held after all the other interviews are completed to provide the Site Visit Team the opportunity to obtain the health department director’s perspectives on issues that the Site Visit Team has identified.

IV. Health Department Walk Through The walk through of the health department is the most flexible agenda item, relative to where it is placed on the agenda. It is important that the Site Visit Team is clear about the length of time allotted to the walk through; the health department may need to be selective about what parts of the department are included in the walk through. For example, walking through similar offices or cubicles in a state office building is not the best use of the Team’s time. (Refer to page 21 of the PHAB Site Visitor Guide, Version 1.0 for more information on the walk through.)

V. Interviews Interviews of health department staff are organized by Domain. An interview should be scheduled for each Domain (even if all measures are met). Domain interviews are scheduled concurrently in the PHAB Site Visit Agenda Template. However, the Site Visit Team may not want to schedule all Domain interviews to be concurrent; there may be some Domains that all Site Visit Team members should attend. In determining this, the Site Visit team should consider:

• Which Domains are those about which the SV Team has the most questions/concerns? These interviews might be conducted with all three Site Visit team members.

• Are there some Domains for which all measures are met? These interviews may be scheduled as concurrent interviews, with only one member of the Team conducting the interview.

Draft October 4. 2012 3

o Consider the number of issues and number of measures when scheduling concurrent interviews so that the lengths of the interviews are about the same.

o Consider the Domain assignments of the Site Visit Team members, so that a Team member is not scheduled for two concurrent interviews at the same time.

When scheduling interviews with representatives of governance and community members, consider that theses interviewees do not work for the health department. Therefore, the middle of the day might be best for them. The Team should consider placing those interviews first thing in the morning (of the second day), or towards the end of the afternoon of the first day. The health department will work with these interviewees and help to finalize this part of the agenda when they receive the Team’s proposed agenda. VI. Executive Sessions Ensure that there are set times for Executive Sessions. The Site Visit Team will probably want to end the first day and begin the second day with an Executive Session. As stated above, an Executive Session must be scheduled to occur immediately before the Exit Conference. These sessions provide the Site Visit Team with opportunities to discuss their observations and findings. These sessions can also be used to finalize assessments and add narrative in the e-PHAB “Build Site Visit Report” section.

Please see the PHAB Site Visitor Guide section on the Site Visit Agenda (pages 20 through 24) and the Agenda Template (pages 41 and 42). Also see Entrance Conference Talking Points, Appendix C, (Pages 43 and 44) and the Exit Conference Talking Points (page 45).

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November 11, 2012

MEMORANDUM

TO: Carol Moehrle, Chair

Board of Directors

FROM: Kaye Bender, President/CEO

RE: Think Tank Report for September Board Meeting

The purpose of this report is to provide the Board with an update on the planned think tanks

previously approved by the Board and to initiate some specific discussion about a few of the

specific think tanks planned for 2013.

New Think Tanks Planned for 2013

1. Ethics – The CDC Ethics Committee, through their Evaluation Subcommittee, has held two

phone discussions with PHAB staff on the possibility of holding a think tank to strengthen and

clarify the PHAB standards and measures in the area of ethics, health equity and social justice.

ASTHO, NACCHO, and NIHB also have an interest in this area and have provided PHAB with

information on their work to date. PHAB had expected to convene a think tank session in late

2012 or early 2013 on this topic. However, after a recent planning discussion with CDC ,

ASTHO, and NACCHO, PHAB staff believe that there needs to be two expert panels, with some

overlap in the membership. One expert panel would discuss public health ethics in its broadest

context. The other expert panel would discuss health equity. Further detailed discussion on the

rationale for the recommendation is planned for the November board meeting. Les Beitsch, Ed

Harrison and Wilma Wooten are the board member liaisons to this think tank.

2. Territorial Think Tank – Several of the territories and US Affiliated States traveled to Atlanta

for the NPHII Conference in May 2012. Kaye Bender organized a breakfast meeting with them

to discuss early planning and interest in a Territorial Think Tank. Attending the meeting were

NPHII representatives from Guam, Puerto Rico, Marshall Islands, and the Republic of Palau.

There was great enthusiasm for the possibility of conducting the same type of work that was

done with the tribes). It was recommended that PHAB ask the Pacific Island Health Officers

Association (PIHOA) to serve as our national partner to organize the activities. A letter was sent

to the PIHOA Board of Directors for their consideration at their June meeting. Kaye Bender and

Jennifer Jimenez met with pacific island public health representatives attending the Global

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Pacific Health Conference. Travis Parker Lee also traveled to Puerto Rico in September to

discuss public health accreditation in their organizational setting.

A detailed presentation will be provided to the Board at the November meeting, with some

specific recommendations on proceeding with this work. Due to the geographical distances

between the territories, it is unlikely that a traditional think tank can be implemented to

accomplish the planned objectives. However, we are optimistic about the work that will be

described to the board.

3. Communication Science – PHAB will convene a Communication Science Think Tank in late

early 2013 for the purpose of strengthening Domain 3. Board member liaisons for this think

tank are Rex Archer, Alonzo Plough, and Harvey Wallace.

Second Sessions of Think Tanks to be Scheduled in 2013

1. Maternal Child Health Think Tank – In partnership with the Association of Maternal Child

Health Programs, PHAB held the MCH Think Tank May 3, 2012 in San Francisco, CA. The

purpose of this think tank is to discuss the relationship between the PHAB standards and

measures and the MCH performance standards and measures; to identify strategies to strengthen

the PHAB standards and measures in the areas of maternal and child health; to identify strategies

to ensure MCH leadership engagement in health department accreditation readiness activities;

and, to identify related program areas managed by health departments that also serve the MCH

population (such as WIC and Children with Special Health Care Needs). An interim report is

being prepared, and further work with a broader MCH group is forthcoming. A possible meeting

in conjunction with the February 2013 AMCHP annual meeting is being considered. Board

member liaisons are Carol Moehrle, Fernando Guerra, Hugh Tilson, and Les Beitsch.

2. Emergency Preparedness Think Tank –In partnership with CDC, PHAB held the Emergency

Preparedness Think Tank June 12-13, 2012 in Atlanta. The purposes of this think tank are to

identify and discuss strategies to ensure emergency preparedness leadership engagement in the

accreditation process (the upcoming accreditation cycle both in their “home” areas as well as

potential site reviewers and then for revision of the standards and measures going forward); to

identify strategies to strengthen the PHAB accreditation standards and measures in the area of

emergency preparedness; to discuss the relationship between the PHAB accreditation standards

and emergency preparedness performance standards/capabilities or other program performance

indicators (this is for continuity in communication as well as looking for opportunities to connect

the dots); and, to identify other public health areas required to support emergency preparedness

that should be included in these discussions and work plans. Board member liaisons are Alonzo

Plough, Bill Riley and Joe Finkbonner. A report is being developed, and a second session will be

planned in February or March of 2013.

3. Informatics Think Tank – In partnership with the Public Health Informatics Institute and CDC,

PHAB held the Informatics Think Tank July 17-19, 2012 in Decatur, GA. The purposes of this

think tank are to identify and discuss strategies to ensure informatics leadership engagement in

the accreditation process (the upcoming accreditation cycle both in their “home” areas as well as

potential site reviewers and then for revision of the standards and measures going forward); to

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identify strategies to strengthen the PHAB accreditation standards and measures in the area of

informatics; to discuss the relationship between the PHAB accreditation standards and any

existing or developmental informatics standards/capabilities; and, to identify other public health

areas associated with informatics that should be included in these discussions and work plans.

also under development at this time. A second session of this group will be held in March or

April 2013. Board member liaisons are Carol Moehrle, Hugh Tilson, and Ed Harrison.

4. Chronic Disease Think Tank - PHAB secured a commitment from the Association of Chronic

Disease Directors to partner with us in planning the Chronic Disease Think Tank. The purposes

of the think tank and a preliminary agenda and date are being planned as of the writing of this

report. Board member liaisons are Fernando Guerra, Bill Riley, Leah Devlin, and Les

Beitsch.

5. California Think Tank – A copy of the initial California Think Tank report was provided to

the Board at the September 2012 meeting. Follow-up discussions are continuing with the

planning advisory committee and through the onsite work of Jennifer Jimenez. A second session,

with broader partner participation, is anticipated in 2013. Board member liaisons are Alonzo

Plough, Wilma Wooten, Fernando Guerra, and Bill Riley.

6. Workforce Think Tank – The Workforce Think Tank was held March 7-8, 2012, facilitated by

High Tilson. The purposes of this think tank are to identify strategies for public health leadership

engagement in workforce aspects of accreditation; to discuss the relationship between the PHAB

accreditation standards and public health workforce competencies; to identify strategies to

strengthen the PHAB accreditation standards and measures in the area of workforce

development; to develop ideas to inform future public health workforce and accreditation

research; and, to identify and discuss strategies to ensure workforce leadership input into the

accreditation process. A second session of this group is planned for 2013. Board member

liaisons are Hugh Tilson, Doug Scutchfield, Paul Halverson, and Bill Riley.

7. Second Large City Metro Think Tank – PHAB has placed the plans for a second Large

City/Metro Think Tank on hold until some results of the larger cities that are currently in the e-

PHAB system have been completed. Many of these applicants were participants in the first think

tank, and their lessons learned will inform the second meeting. PHAB anticipates it will be later

in 2013 before we have adequate information upon which to hold that second think tanks. Rex

Archer, Alonzo Plough, Fernando Guerra, Bill Riley, and Leah Devlin are the board

liaisons to this think tank.

8. Army Mini-Think Tank – Although not officially titled as one of PHAB’s Think Tanks, the

Army invited PHAB over to the Army Proving Ground (APG) in Edgewood, MD, on May 22,

2012 for a mini-think tank. The purpose was to learn more about the Army’s public health

services and to provide them with additional information about PHAB. Attending the meeting for

PHAB were Hugh Tilson, Kaye Bender, Mark Paepcke, and Robin Wilcox. Approximately

fifteen people attended for the Army. The Army’s ongoing interest is in whether it is desirable

and feasible for their public health services, both centrally at the APG, and locally at the

installation level (n=44), would be eligible for PHAB accreditation. If so, then, a process for

considering the development of an Army category of public health accreditation would need to

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be developed (somewhat similar to the work completed with the tribes). The Army plans to

conduct their own follow-up work to determine the most appropriate next steps. There have been

no additional requests of PHAB since that meeting, although conversations continue.

Thank you for the opportunity to provide this report. I look forward to the discussion at the

upcoming board meeting.

November 9, 2012

MEMORANDUM

TO: Carol Moehrle, Chair

Board of Directors

FROM: Les Beitsch and Bill Riley, Co-Chairs

Research and Evaluation Committee

RE: Discussion Material for PHAB Board of Directors

As the Board of Directors is aware, the Research and Evaluation Committee (R and E) has been

very active with PHAB’s development over the past five years. As we move forward with

PHAB’s next phases, it is important that we review the role of this committee and how it can be

the most productive in the future. At the last R and E Committee meeting, a recommendation

was made for the PHAB Board of Directors to consider incorporating the new body of work

related to quality improvement into the role of this committee. There are no increases in the

PHAB budget associated with these recommendations.

These materials were discussed at the September board meeting in order to get the board’s initial

feedback about these changes. We have made a few edits based on that discussion and are now

requesting board approval at the November meeting. The edits are noted in bold font.

Recommendation 1

Thank the current members of the Research and Evaluation Committee for their work in

assisting PHAB’s development to this point and notifying them of the changes in the

committee and the rationale. Since most of them assisted us with developing these changes,

there should be no surprises in this recommendation.

Recommendation 2

Proposed Change in Committee Name:

The proposed change in the committee name is Evaluation and Quality Improvement

Committee.

Rationale for Proposal:

Given that the research agenda has been promulgated, at this time it is appropriate to focus

the Committee’s work on providing guidance related to ongoing evaluation activities. In

addition, this Committee will also contribute to strengthening the link between accreditation

and quality improvement, a key area for consideration as accreditation is implemented.

Proposed Evaluation and Quality Improvement Committee Charter:

1. Purposes

The Evaluation and Quality Improvement Committee shall provide the following functions:

a. Provide guidance in the ongoing development of PHAB’s evaluation activities as

related to the overall PHAB evaluation plan.

b. Assist in the development and implementation of PHAB’s activities aimed at

supporting health department quality improvement, as manifested by the annual health

department QI reports and the related PHAB QI reporting structure.

2. Committee Membership

The Committee Chair will be a member of the Board of Directors. Non-board committee

members (9) will be recommended to the PHAB Nominating Committee and approved

by the Board of Directors. In addition to the 9 non-board committee members, up to two

additional board members may serve on the committee, based on the interest and expertise of

those board members. Committee members will have experience in public health practice,

program and systems evaluation, performance management and quality improvement.

National partner organizations may also be asked to participate as appropriate.

3. Key Responsibilities

The Committee shall provide guidance toward the development and implementation of

PHAB’s accreditation evaluation activities; promote quality improvement in the overall

accreditation program; and advise PHAB on specific metrics by which the accreditation

program would be assessed over time. It will also work in consultation with PHAB

management to inform the development and implementation of strategies to monitor and

enhance the link between accreditation and quality improvement in public health, including

activities related to the annual QI reports and the QI database.

Recommendation 3

Proposed Additional Advisory Council for PHAB:

In order to continue to support the role of PHAB in informing the development of

accreditation related research and the science-base for accreditation, the recommendation is

that PHAB appoint a small, research advisory council to serve in an ad-hoc advisory capacity

to PHAB, and in particular to serve as a resource to the Director of Research and Evaluation.

Rationale for Council:

Building upon earlier work to develop the research agenda, this advisory council will

continue to promote research. On an as-needed basis, it will also serve in an advisory

capacity in developing PHAB research policies and guidelines and in reviewing articles.

Proposed Council Name:

The proposed committee name is Research Advisory Council.

Proposed Council Charter:

1. Purposes

The Research Advisory Council shall assist the Board of Directors in its oversight of the

organization's public health research activities, to encourage research to develop the science

base for accreditation and systems change in public health, and to contribute to the science

base for public health.

2. Council Membership

Council members (5) will be approved by the PHAB Executive Committee. Public health

systems researchers shall comprise a majority of the membership of the Council. Since this

Council is advisory to the PHAB Director of Research and Evaluation, an appointed

chair is not required.

3. Key Responsibilities The Council shall promote research that would improve the standards-setting and

accreditation program; promote the identification and discussion of issues regarding

accreditation research; influence the development and implementation of initiatives relevant

to achieving and sustaining appropriate research; guide the development of PHAB research

agreements and policies (e.g., data use agreements); and, review proposed PHAB research

articles aimed at strengthening the science base for accreditation. This latter function

fulfills the Publications Committee responsibilities requested by the Board of Directors.

Additionally, the Council will serve as a conduit for technical assistance, providing input

into policy, and engaging in other support activities deemed necessary to advance

accreditation related research.

Relationship Between Research, Evaluation, and QI

What? Which

Committee?

What Role Will PHAB Play? Will It Support Improvements by

PHAB? Will It Support Improvements

by HDs? In Research In Evaluation Other Improve Standards

and Measures Improve PHAB

Processes

Annual reports Evaluation and QI

PHAB to develop policy for reports and to review them

X (In reviewing

reports, PHAB may identify areas for

strengthening S&M)

X

QI Database Evaluation and QI

PHAB to develop

X

Connection between QI and accreditation

PHAB to consider how QI is reflected in re-accreditation and elsewhere in accreditation process

X X

Other support for QI among HDs

Evaluation and QI

PHAB to determine how to include QI in Annual Accreditation Conference PHAB to promote or provide

X

Formative/process evaluation

Evaluation and QI

PHAB to fund some evaluation activities PHAB to conduct some evaluation activities

X

What? Which

Committee?

What Role Will PHAB Play? Will It Support Improvements by

PHAB? Will It Support Improvements

by HDs? In Research In Evaluation Other Improve Standards

and Measures Improve PHAB

Processes

Research on the impact of public health accreditation

Evaluation and QI & Research Advisory

PHAB to promote research about public health accreditation (i.e., to fill in the logic model about the links between strategies, outputs, outcomes)

PHAB to promote and potentially to fund and/or provide data for summative evaluation of PHAB accreditation

X X

Evidence base around QI

Evaluation and QI & Research Advisory

PHAB to promote research

X

Evidence base around the content of the standards (e.g., what are promising practices around governance)

Research Advisory

PHAB to promote research and potentially to provide data

X

X

Other research about accreditation (characteristics of HDs that apply/don’t apply, amount of time HDs spend on accreditation preparation, etc.)

Research Advisory

PHAB to promote and potentially to fund, conduct, and/or provide data for research

X (PHAB can use to identify/foster

pool of applicants)

X (If national

partners use for TA

provision)

Clearinghouse of PHAB-related articles

Research Advisory

PHAB committee to review manuscripts of publications written by PHAB staff or by board members/other stakeholders who seek PHAB review)

What? Which

Committee?

What Role Will PHAB Play? Will It Support Improvements by

PHAB? Will It Support Improvements

by HDs? In Research In Evaluation Other Improve Standards

and Measures Improve PHAB

Processes

Recommendation of metrics of high-performing health departments

Evaluation and QI & Research Advisory & Board

PHAB to develop or promote the development of

PHAB to use, or promote the use of, in evaluation

X (Potentially

incorporate in accreditation

determination)

X